University of Dundee

The Hall Technique

A child centred approach to managing the carious
primary molar

A Users Manual

Text copyright Nicola Innes & Dafydd Evans

Illustrations copyright Dafydd Evans & Amy McKay

Introduction
The Hall technique is a novel method of managing carious primary molars by cementing preformed metal crowns, also known as stainless steel crowns, over them without local
anaesthesia, caries removal or tooth preparation of any kind. Clinical trials have shown the
technique to be effective, and acceptable to the majority of children, their parents and
clinicians. The Hall technique is NOT, however, an easy, quick fix solution to the problem of
the carious primary molar. For success, the Hall technique requires careful case selection, a
high level of clinical skill, and excellent patient management. In addition, it must always be
provided with a full and effective caries preventive programme (see Appendix).
Provision of a conventional preformed metal crown for a lower E

Provision of a preformed metal crown with the Hall technique for a lower E

The Hall technique will not suit every tooth, every child or every clinician. It can, however, be
a useful and effective method of managing carious primary molars. This manual is intended
as a guide to developing some skills in the application of the technique.

Background
The technique is named after Dr Norna Hall, a general dental practitioner from Scotland, who
developed and used the technique for over 15 years until she retired in 2006. Preformed
metal crowns (PMCs) have been used for restoring primary molars since 1950, and have
become the accepted restoration of choice for the primary molar with caries affecting more
than one surface, with a proven success rate as a restoration. Although popular with
specialists, many clinicians find PMCs difficult to fit using the conventional approach, which
requires the use of local anaesthetic injections and extensive tooth preparation. There is also
an issue of potential damage to the adjacent first permanent molar when preparing a second
primary molar for a PMC. For this, and other reasons, PMCs are not widely used in the UK,
forming less than 1% of all restorations provided for children.
How does the Hall technique get around some of these problems?
With the Hall technique, the process of fitting the crown is quick and non-invasive. The crown
is seated over the tooth with no caries removal or tooth preparation of any kind, and local
anaesthesia is not required.
For decades, conventional teaching has been that all carious tooth tissue should be
removed before restoring the tooth, unless there is a high risk of pulpal exposure.
How can leaving all the caries in the tooth be acceptable?
To answer this, it is worth firstly reviewing how and where caries begins. For many years it
was assumed that all that was needed was to put a tooth surface, plaque and sugar together,
add a little time, and caries would result. This combination can undoubtedly, under the right
circumstances, cause caries, but what is remarkable is that so few tooth surfaces seem to be
susceptible to carious attack. Clinicians will be aware that, except in extreme cases, the
majority of tooth surfaces are relatively immune from caries, despite many of these surfaces
often having prolonged coverage by plaque; for example, the labial and buccal cervical
margins of teeth as they approach the proximal surfaces.
Low caries susceptibility

High caries susceptibility

In fact, almost all caries begins at sites which collectively make up only a tiny proportion of the
total area of enamel available for colonisation; the base of fissures, and just below the contact
point of proximal surfaces. The enamel here is almost identical in composition to that of the
labial surfaces, so why the difference? What differs is the ecological niche provided for
plaque maturation by the very sheltered environment of these surfaces. Once caries has
caused cavitation of the tooth, the availability of sheltered surfaces suitable for plaque
colonisation and maturation dramatically increases, and so the caries continues through the
tooth.

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Plaque is far from the bland, homogenous material it appears to the naked eye. Given time,
and a stable environment, plaque will mature into a complex, organised structure, with
channels and pores. Its bacterial population will shift and change in composition, with
symbiotic relationships developing between some species, while other species will be
gradually squeezed out by their neighbours. In the deeper layers, organic acids formed as a
by-product of bacterial metabolism, will favour a shift in the bacterial composition from noncariogenic species such as Streptococcus oralis and Streptococcus salivarius to more
cariogenic species such as the mutans streptococci and lactobacilli. Plaque has been
described by Marsh as a city of slime. This is a useful analogy because just as a city is a
complex structure, whose smooth functioning can be interrupted by a change in the supply of
any number of factors (water, oxygen, power, light), so can the cariogenic potential of plaque
be altered by changing the supply of carbohydrates, oxygen, or the pH.

Travelling through the plaque biofilm After Marsh

The Hall technique manipulates the plaques environment by sealing it into the tooth,
separating it from the substrates it would normally receive from the hosts diet. The plaque
may continue to receive some nutrition from pulpal perfusion, but there is good evidence that
if caries is effectively sealed from the oral environment, it does not progress.
That might apply for the early enamel lesion, but what about the soft dentinal lesion?
Most clinicians will be familiar with this clinical picture. Perhaps
because the cavity has become self cleansing, or the childs diet has
changed, the caries has arrested, with the colour changing to dark
brown or black. It will be hard to the probe. What was once soft and
active is now hard and there may even have been some
remineralisation. The evidence that caries can arrest is visible to us
on a daily basis, yet we continue to provide management therapies
(conventional restorative treatment) based on its complete excision.

How does the pulp react to caries?

Just as it is becoming increasingly clear that dental caries is a dynamic process, it is also
being recognised that the dentine/ pulp complex is far from passive when exposed to dental
caries. Instead, these tissues mount an active defence response from the earliest stages of
carious lesion formation in the enamel. An increase in pulpal blood flow allows an increased
response from the immune system, and odontoblasts are stimulated to lay down a layer of
secondary dentine in an effort to distance the pulp from the approaching carious lesion, an
effect readily observed, at a gross level, on radiographs.

It seems likely that the dentine/ pulp complex has a greater

reparative potential when subject to dental caries than has
previously been thought. If the progress of the caries can be
halted before the pulp is overwhelmed, then the pulp may well
survive.

Summary
Not all plaque is cariogenic. Plaque which has matured in a sheltered environment to achieve
cariogenic potential can lose that potential if its environment is altered. Effective sealing from
the oral environment can cause the necessary alteration, resulting in plaque losing its
cariogenic potential for as long as the seal is maintained, and allowing dentinal caries to
arrest. The Hall technique is one method of achieving that seal for primary molar teeth.

Is the Hall technique effective?

To answer this question, a clinical trial set in 9 general dental practices in Tayside, Scotland
looked at outcomes at two years for teeth where a Hall crown was fitted, compared to teeth
which had undergone conventional restorative treatment. The trial was a split mouth
randomised control design, so teeth were matched on each side of the arch for type of lesion
and extent of caries. The dentists telephoned a distant operator to be told which tooth to
provide a Hall crown and which to fit first, in order to reduce any bias in the trial. 132 children
were enrolled in the trial and followed up every year clinically and with bitewing radiographs.
The outcomes for the 124 patients seen at 2 years (8 patients failed to return for 2 year
appointments) are shown below.
Outcomes

pain

major failures (irreversible pulpitis; abscess requiring pulpotomy or extraction; interradicular radiolucency; filling lost and tooth unrestorable)

minor failures (new/secondary caries; filling/crown worn, lost or requiring other

intervention; restoration lost but tooth restorable; reversible pulpitis treated without
requiring pulpotomy or extraction)

Main outcomes after 2 years for 124 conventionally treated teeth and 124 Hall teeth
main outcomes at 2 years

50

conventional
restoration

50
45

Hall technique

number of teeth

40
35
30
25
20

13

15

11

10

5
5

pain

major failures

minor failures

type of outcome

And is the Hall technique acceptable to children, their parents

and dentists?
In the same clinical trial, the children, their parents/ carers and dentists stated whether they
preferred the Hall or conventional restoration when both procedures were completed.
patient/ carer/ dentist preference (n=132)
97

95

100

Conventional
restoration

90

number of individuals

83
Hall technique

80
70

No preference
expressed

60
50
40
30

32

28
17

20

23
12

10
0

child

parent/carer

dentist

Using the Hall technique in clinical practice

Indications, and some important information

The Hall technique is can be used to manage primary molar teeth affected by dental caries.
Other management methods are available. As with every treatment decision, clinicians
should use their own clinical judgement in deciding which method is appropriate for their
patient and themselves, with consent being obtained from the patient, and parent, for that
treatment. Although apparently very simple, the Hall technique requires a confident, skilled
approach from the operator if the crown is to be successfully fitted. The technique will not suit
every clinician, nor every child. In addition, there are some primary molars where, for a
combination of reasons, even clinicians very familiar with the Hall technique cannot
successfully fit a crown.
For example, should these lower Ds become
carious, their unusual morphology would
complicate the fitting of a PMC of standard
shape.

Again, common to all clinical procedures, it is important that the clinician has a clear
understanding of what to do to retrieve a situation which is not proceeding as planned, for
example when a Hall crown is not seating properly onto a tooth or appears to be the wrong
size or shape and will not fit correctly over the crown of the tooth. These issues are dealt with
at the end of this section.
To begin with
A full history and clinical examination, including bitewing radiography, should be carried
out.
There should be no clinical or radiographic signs of pulpal involvement
The tooth should have sufficient sound tissue left to retain the crown
Patient co-operation should be such that the clinician should be confident that the
crown can be fitted without endangering the patients airway
If the patient is at risk from bacterial endocarditis, the tooth should be managed with a
conventional restoration

The appointment for fitting the crown

Preparation is everything! The child and parent should be briefed on the procedure.
Children should be shown a crown, and allowed to handle a spare one if felt beneficial.
Young children sometimes respond to the idea of the crown being a shiny helmet,
just like soldiers wear to protect their heads, or a precious, shiny, princess crown or
it being a twinkle tooth.

It is important that the child knows that:

a) they will have to help, by biting the crown into place when asked to do so
b) the cement will taste a bit like Salt & Vinegar crisps

Instruments to have ready

Essential:
Mirror
Straight probe
o to remove separators, if used, and to remove set cement following fitting
Excavator
o to remove crown if necessary, and also useful for cement removal
Flat plastic
o to load crown with cement
Cotton wool rolls
o to wipe away cement
Useful:
Orthodontic biting stick
o can be useful in seating crowns
Band forming pliers
o can be useful for adjusting crowns, particularly where the primary molar
has lost length mesio-distally due to caries
Gauze to protect the airway and wipe off excess cement
or
Elastoplast to secure the crown for airway protection

Assess the shape of the tooth and its contacts

Placing orthodontic separators through the mesial
and distal contacts can be very useful when fitting
crowns with the Hall technique, especially if the
contact points are tight, or there has been loss of
mesio-distal width of a tooth due to marginal ridge
fracture. It does, though, mean the patient will have to
make a second visit. Two lengths of dental floss
should be threaded through the separator.

The separator should then be stretched taut, and

flossed through the contact point briskly and firmly
until the leading edge only is felt popping through the
contact point.

If the separator is cut

by sharp cavity margins, it may be found helpful to pull the
separator up, into & through the contact area, approaching
from the cervical margin.

The floss should then be

removed, and the patient seen
between 3-5 days later for
removal of the separator.

If the separator appears to have

fallen out, the inter-proximal area of the gingiva should be inspected to check that the
separator hasnt worked its way below the contact point. Separators are usually brightly
coloured to facilitate this.

Oh, the separator has fallen out

No it hasnt!!

Another difficulty can be placing crowns on Ds where the distal marginal ridge has been lost,
and the E has migrated mesially into the cavity.

Here, band forming orthodontic pliers can

be useful, both to increase the buccolingual width of the crown at the expense
of the mesio-distal length (here using the
pliers the right way around, that is with
the curvature of the pliers following the
curvature of the crown),

and also, if necessary, to

alter the distal margin of
the crown from a convex
to a concave shape, by
gently squeezing the
margin with the pliers the
wrong way around.

The procedure
1. Sit the child upright. A gauze swab square can be used to protect the airway by
placing it between the tongue and the tooth where the crown is to be fitted. It should
extend to the palate and round the back of the mouth in front of the fauces.
Alternatively, use a clean piece of Elastoplast tape to secure the crown (see below). If
you are not confident about being able to control the crown at all stages until it is
cemented, then do not use the Hall Technique.
Airway protection using a) a gauze square

b) Elastoplast

Orientation of gauze

Elastoplast tape securing crown

Positioned in mouth

2. You should aim to fit the smallest size of crown which will seat. Select one which
covers all the cusps, and approaches the contact points, with a slight feeling of spring
back. Do not attempt to fully seat the crown through the contact points; they
can be very difficult to remove for cementation!
3. Dry the crown, and fill with glass-ionomer luting cement, ensuring the crown is well
filled, with no air inclusions
4. If possible, the tooth should be dried prior to cementation, but otherwise there is no
caries removal or tooth preparation of any kind. No local anaesthetic injection is given.
5. If the cavity is large, some cement may be placed within it, just before placing the
crown.
6. Place the crown over the tooth. Fully seating the crown is a critical stage! It is not
always easy, and requires a committed, positive approach from the clinician. The child
needs to have complete confidence that you know exactly what you are doing; that
what you are asking them to do is perfectly reasonable, and that it will not be
uncomfortable. Remember that our research found that, surprisingly, most children
do not find the procedure painful, and prefer it to conventional fillings. There are two
main methods of seating the crowns:
a) the clinician seats the crown by finger pressure
b) the child seats the crown by biting on it
A combination of these two methods may be necessary or preferred.
Some clinicians will seat the crown with firm finger pressure alone. For mandibular
teeth, a useful method is to place your thumb on the occlusal surface of the crown, with
the four fingers of your hand placed under the border of the mandible to spread the
force as you apply firm pressure with your thumb. For maxillary teeth, the childs head

may be supported by the back of the dental chair, or sometimes by placing your other
forearm gently on the top of their head to balance the force applied by fitting the crown.
Often, the child will seat the crown themselves by biting it into place. It can be useful
to verbally encourage the child to apply the necessary pressure (Bite hard, like a
Tiger! Grrrrr..!), and to rehearse this before fitting the crown. If using this method, be
aware that some childrens resolve might falter a little, leaving the crown not fully
seated. Here, a timely That was great! Now let me just check it for you! Ooh, well
done, and Ill just give it a little squeeze.., Excellent! can save the day.
Some clinicians partially seat the crown until it engages with the contact points,
allowing the finger to be removed without risk of the crown falling off, and the child then
being encouraged to bite the crown into place. It must be remembered that your
working time with glass ionomer cements is limited, and whatever method is used, you
must work smoothly and efficiently. Crowns cannot be seated, no matter how hard you
or the child tries, if the cement has started to thicken!
It is crucial that the orientation of the crown relative to the tooth is checked either
during, or immediately after, seating the crown. If it does not appear to be going on
straight, then you must give the crown some physical encouragement to go in the
correct direction. If it is not possible to seat it then it should be removed before the
cement sets.
With either technique, excess cement will be extruded from the crown margins, and the
taste of this can upset children. In anticipation of this, as soon as the crown is seated,
the child should be asked to open their mouth, and the cement wiped off with a cotton
wool roll held ready for this purpose. If a gauze swab has been used to protect the
airway, this can be used to wipe away excess cement from the lingual/ palatal side of
the tooth as it is being removed.
If it is obvious that the crown has not seated, and finger pressure fails to seat it, then it
should be removed immediately using the large excavator which you should have
placed within easy reach. If you do not work swiftly, you may have to section the
crown to remove it (see later).
7. Once excess cement has been removed, the child should be asked to bite firmly on the
crown for 2-3 minutes, or the crown should be held down with firm finger pressure as
an alternative. This is important, because the crowns can spring back a short way,
sucking back the cement form the margins and potentially causing breaches in the
seal.
8. Remove excess cement (beware, we have seen a few cases where a shelf of set
cement has been left buccal to maxillary Es, and has remained there for several
weeks), floss between the contacts and give the child a sticker.

Picture Gallery
Working with the child seated upright
means that the optimum operator working
position has to be compromised.

Mix the cement to a luting consistency, and

rapidly, so as to maximise working time.

Load crown generously (it should be

almost full with cement). Take care to
avoid air blows and voids.

What happens if you dont (fortunately this

one didnt seat!).

Some glass ionomer may be wiped on the

tooth or placed in any cavitation to improve
the seal. The crown is placed evenly over
the tooth and engaged in the approximal
contact points using finger pressure. This
secures its position. The child is instructed
to bite down on the crown. Some
operators find biting on a cotton wool roll
helps the process. Care is taken to ensure
the crown seats evenly over the tooth.

Blanching usually disappears within

minutes.

The occlusal discrepancy should resolve in

a few weeks. Floss should be used to
clear the contacts of any excess cement.

A satisfied customer, with a restored occlusion!

If the crown does not seat sufficiently, then remove it using the excavator before the cement
sets. If the cement has set, a high speed handpiece can be used to section the crown
through the buccal and occlusal surface, following which it can easily be peeled off.
PMC being sectioned (yellow material is Duraphat varnish applied to mesial of the 6)

Important additional notes

1) The crowns used in the research presented here were Ni-Cro Primary Molar Crowns,
cemented with AquaCem, both from 3M/ESPE. Any adjustment of the crowns was minimal,
and was limited to re-molding the crown margins in some cases with orthodontic band forming
pliers. No crown had the margin trimmed.
2) Fitting crowns to Ds where loss of the marginal ridge has allowed the E to drift mesially
can be tricky. Use of separators is
particularly helpful, and adjusting the shape
of PMCs using band forming pliers has already
been mentioned. Sometimes it helps if the
PMC is rotated slightly, usually mesio-buccaly.
This example is a little extreme! Another
solution is to place a temporary dressing of
Polycarboxylate cement, which allows you to
place a separator, so that you can then place a
PMC next visit, in 3-5 days time.

3) Crowns will try to follow the path of least resistance, and so may tilt towards the easier of
the contacts, making it almost impossible then to ease the crown through the tight contact.
Concentrate on seating the crown through the tight contact, and the easy one should take
care of itself. If fitting a Hall crown for the first time, try Es, rather than Ds.
4) If the crown does not seat sufficiently, then remove it using the excavator before the
cement sets. Do not leave a child with the bite propped open excessively! If the cement
has set, a high speed handpiece can be used to section the crown through the buccal and
occlusal surface, following which it can easily be peeled off.
5) Patients and parents should be reassured that the child will be used to the feeling within
24 hours. It is the authors experience that analgesia is not required. The occlusion tends to
adjust to give even contact on both sides within weeks.
6) Patients should be reviewed on a normal recall schedule, and the Hall technique should
be used in conjunction with a full preventive programme.
7) If fitting crowns to Es, particularly maxillary Es, before the 6s are
erupted, keep an eye out for the 6s becoming impacted against the
crown margin as they erupt. This can occur even if crowns havent
been fitted, and there is no evidence from the authors clinical trial that
there is an increased risk of this. Nevertheless, if it does occur, it can
often be managed with orthodontic separators if detected early.

8) If a molar fitted with Hall crown becomes non-vital, a pulpotomy can be carried out through
the crown without needing to remove it.
10) In the authors experience, it is usually not possible to fit a crown using the Hall
technique to a D and an E in the same quadrant at the same appointment; they will need
to be fitted at separate appointments. In addition, directly occluding (opposing) Hall
crowns should only be fitted once the bite has adjusted to the fitting of the first crown,
with the second crown being fitted (usually) three months later. Attempting to fit
opposing Hall crowns at the same appointment can prop open the bite beyond the level which
a child can find comfortable. Fitting, say, both upper Es at the same appointment, rather
than separate appointments, is a good idea (provided both Es needed Hall crowns!), as the
bite will be more comfortable for the child, and the overall bite propping will probably be
reduced. Similarly, the same will apply if fitting diametrically opposite crowns (an upper left E
and a lower right E, for example).

11) Occasionally a crown will wear through occlusally.

If this occurs, it can be repaired with composite
material.

12) The Hall technique must not be used on teeth with

either obvious pulpal involvement clinically, or with
insufficient tooth tissue remaining to retain the crown. If
the tooth is unrestorable by a conventionally fitted PMC, then it
is probably not suitable for a Hall crown.

Final note
The field of cariology, and management of the carious primary molar, is rapidly changing.
Please let us know of your thoughts and comments regarding the Hall technique, or on any
other matter relating to management of the carious primary dentition.
Nicola Innes n.p.innes@dundee.ac.uk
Dafydd Evans d.j.p.evans@dundee.ac.uk

Prevention that works!

There are several ways of helping children reduce the risk of developing further dental decay.
Four very important methods are:
Brushing

Topical fluoride varnish

Fissure sealants

Diet advice

The following are the key points for each method. For further information regarding the
evidence base for these recommendations, look at SIGN Guideline 83, available at
www.sign.ac.uk

Brushing
Fluoridated toothpaste (1000ppmF from 6 months of age if child assessed as being at
increased caries risk, then 1,500ppmF when 7 years or older)

Twice daily

Pea sized amount (smear if < 2 years of age)

Spitting out, NOT rinsing, after brushing

Supervised if < 7 years of age

Topical fluoride varnish

Apply 2 to 3 times a year for children you think are at risk of developing caries
Follow manufacturers instructions:

Fissure sealants
Fissure seal all susceptible pits and fissures in children you think are at risk of developing
caries

Diet advice
Sugar and sugar containing foods and drinks should be restricted to meal times. Between
meals, children should snack on fresh fruit or cheese, and drink milk or water

References and further information

Sealing in caries
1. Ricketts, D.N., Kidd, E.A., Innes, N. and Clarkson, J., 2006. Complete or ultraconservative
removal of decayed tissue in unfilled teeth. Cochrane database of systematic reviews
(Online), 3.
2. Marsh PD. Dental plaque as a microbial biofilm. Caries Research 2004; 38(3): 204-11.
3. Riberio, C.C.C., Baratieri, L.N., Perdigao, J., Baratieri, N.M.M., Ritter, A.V., 1999 A clinical
and radiographic, and scanning electron micrscopic evaluation of adhesive restorations on
carious dentin in primary teeth. Quintessence International 1999; 30(9):591-9.
4. Paddick, J.S., Brailsford, S.R., Kidd, E.A.M. and Beighton, D., 2005. Phenotypic and
genotypic selection of microbiota surviving under dental restorations. Applied and
Environmental Microbiology, 71(5), pp. 2467-2472.
5. Going RE, Loesche WJ, Grainger DA, Syed SA. The viability of microorganisms in carious
lesions five years after covering with a fissure sealant. Journal of the American Dental
Association. 1978; 97: 455-62.
6. Handelman ,S.L., Leverett, D.H., Espeland, M.A. and Curzon, J.A., 1986. Clinical
radiographic evaluation of sealed carious and sound tooth surfaces. The Journal of the
American Dental Association, 113(5), pp. 751-754.

The Hall Technique

7. Innes, N.P.T., Stirrups, D.R., Evans, D.J.P., Hall, N. and Leggate, M., 2006. A novel
technique using preformed metal crowns for managing carious primary molars in general
practice - A retrospective analysis. British Dental Journal, 200(8), pp. 451-454.
8. Innes N.P.T., Evans D.J.P., Stirrups D.R., 2006. Clinical pulpal responses to sealing caries into
primary molars: 2 year results of an RCT. Caries Research, 40: 327.
9. Evans D.J.P., Innes N.P.T., Stirrups D.R., 2006. Longevity of Hall technique crowns compared
with conventional restoration for primary molars; 2 year results. Caries Research; 40: 327.
10. Evans, D.J.P., Southwick, C.A.P., Foley, J.I., Innes, N.P., Pavitt, S.H. , and Hall, N., 2000. The
Hall technique: a pilot trial of a novel use of preformed metal crowns for managing carious
primary teeth. Tuith http://www.dundee.ac.uk/tuith/Articles/rt03.htm
11. Innes N.P.T., Evans D.J.P., Stirrups D.R. 2007 The Hall Technique; a randomized controlled
clinical trial of a novel method of managing carious primary molars in general dental practice:
acceptability of the technique and outcomes at 23 months. BioMed Central Oral Health in press
12. Innes N.P.T. An investigation into the Hall Technique; a novel method for managing dental caries
in primary molar teeth. PhD. University of Dundee 2007